Evidence-Based Answer

Practice Pointers

The U.S. Preventive Services Task Force1 and U.S. Department of Health and Human Services2 recommend that physicians screen all adults for tobacco use and recommend intervention for those who report using tobacco products. There is good evidence that brief behavioral counseling and pharmacotherapy increase rates of abstinence. More intensive counseling has a dose-response relationship, with more minutes of contact producing better results. Nicotine replacement and bupropion have been approved by the U.S. Food and Drug Administration for use in smoking cessation.

Hughes and colleagues reviewed the literature to see if other antidepressants also improve rates of smoking cessation. All trials had at least six months of follow-up. Although nortriptyline and bupropion had the most studies meeting the inclusion criteria, there were also trials on sertraline, venlafaxine, and fluoxetine. Patients taking bupropion (19.3 versus 10.2 percent; pooled odds ratio [OR], 2.0; 95 percent confidence interval [CI], 1.7 to 2.3) or nortriptyline (18.5 versus 7.6 percent; pooled OR, 2.8; 95 percent CI, 1.8 to 4.3) had long-term abstinence rates higher than in those taking placebo. One small trial comparing bupropion with nortriptyline did not show a statistically significant difference. In five studies of SSRIs (largely fluoxetine) with 1,521 patients, there was no significant difference between treated patients and control patients in rates of long-term abstinence. This systematic review did not address the question of whether combining pharmaceutical and counseling interventions produces higher quit rates. However, patients who report using tobacco should receive at least a brief counseling intervention and an offer of medication.